Christina Zapletal

Value of donor swabs for intra-abdominal infection in simultaneous pancreas-kidney transplantation.

Background. Simultaneous pancreas-kidney transplantation (SPK) has a higher rate of surgical complications compared with other whole organ transplantations. Graft thrombosis and intra-abdominal infections are the most frequent causes for relaparotomy. We evaluated risk factors for abdominal infections after SPK, with emphasis on the value of the routinely taken intraoperative swabs. Methods. Between June 1994 and December 2000, 177 SPK were performed. Immunosuppression consisted of antithymocyte globulin induction and triple-drug maintenance therapy. Routine swabs were taken from the graft perfusion solutions, from the donors’ duodenum, and from the recipients’ bladder and jejunum (in case of enteric drainage). Results. A total of 19 (10.7%) of 177 patients underwent 41 relaparotomies as a result of intra-abdominal infections. Positive microbial results from any donor site and positive duodenal swabs were significant risk factors for intra-abdominal infections after SPK (P =0.01, P =0.02). There was a significantly higher incidence of abdominal infections when Candida was found in the donor duodenal swab (P =0.0048). Patient survival was significantly lower in cases with abdominal infection (P =0.02). Survival rates of patients with and without abdominal infection were 89.5% and 97.4% at 1 year and 72.3% and 92.8% at 5 years, respectively. Conclusions. The results of this study confirm that abdominal infections significantly reduce patient survival and thus jeopardize the success of SPK. Positive donor duodenal swabs have been revealed to be a significant risk factor for a subsequent intra-abdominal infection, especially when Candida was found.

Induction of HSP70 shows differences in protection against I/R injury derived by ischemic preconditioning and intermittent clamping

BACKGROUND Ischemic preconditioning (IP) and intermittent clamping (IC) increase the ischemic tolerance of the liver. The underlying mechanisms are not completely understood. Heat shock proteins protect cellular integrity in stress and have been discussed as mediators in preconditioning. IP and IC in rat livers were compared with respect to HSP induction and postischemic microcirculation. METHODS All animals were exposed to 70min of partial warm liver ischemia. Different clamping protocols were used: in control animals (C) 70min continuous ischemia was applied. IP was performed by 5min ischemia and 10min reperfusion before the 70min ischemia time. In IC-groups, ischemia time of 70min was divided into four intervals. Each group included 21 animals with 3 different reperfusion intervals; either 30min, 12 or 36h. Intravital microscopy was performed after 30min of reperfusion. AST-levels and HSP induction were analysed 90min, 12 and 36h after reperfusion. RESULTS IP and IC significantly improved sinusoidal perfusion (IP: 83.4±2.8%; IC: 84.4±4.6% vs. C: 60.4±3.9%; p<0.001) and leucocyte adherence in sinusoids (IP: 51.9±12.0, IC: 40.9±4.7 vs. C: 90.1±17.7/mm(2) liver surface; p<0.001) and postsinusoidal venules. AST-levels were minimized in IP and IC compared to controls (12h after reperfusion: IP: 969±934U/l, IC: 675±562U/l vs. C: 2373±792U/l; p=0.004). In the course of reperfusion HSP70 protein expression doubled between 90min and 12h in IC (0.529±0.227 vs. 0.992±0.246; p<0.05) and control-groups (0.572±0.314 vs. 1.106±0.309; p<0.05) whereas it remained unchanged in the IP-group (0.437±0.383 vs. 0.412±0.439; n.s.). CONCLUSION Microcirculation is similarly preserved by IP and IC. The early protection derived by IP prevents further induction of HSP70 in opposite to IC. Therefore, IP may offer a more comprehensive protection against I/R on a cellular and transcriptional level.

Prothrombotic disorders in uremic type-1 diabetics undergoing simultaneous pancreas and kidney transplantation

Background. Although prothrombotic disorders (PTD) are known to increase the risk of graft failure in kidney transplantation only, there are no data on PTD in simultaneous pancreas and kidney transplantation (SPK). Methods. Forty-seven SPK performed between September 2000 and July 2002 underwent routine screening for PTD. Data were retrospectively analyzed in view of complications (relaparotomy, graft thrombosis, pancreatitis, rejection) and graft function (HbA1c, serum creatinine) 3 months posttransplantation. Results. Twenty-five of forty-seven (53.2%) patients had 30 PTDs. Homozygous mutations of the MTHFR gene (C677T) were found in six, factor-V Leiden mutation (homo- or heterozygous G1691A) in seven, and prothrombin mutation (20210A) in one patient (group 1). Group 2 consists of deficiencies of protein C (n=1), of protein S (n=12), of antithrombin (n=1), and antiphospholipid syndromes (n=2). Overall, PTD had no influence on graft thrombosis (P =0.36) or rejection (P =0.56). In patients with homozygous mutations, relaparotomies were more often necessary than in patients without mutations (42.9% vs. 11.8%, P =0.046). In group 1, there was a trend toward a higher incidence of graft pancreatitis than in patients without mutations (38.5% vs. 14.7%, P =0.075). Three months posttransplantation, HbA1c was 6.0% in patients with and 5.5% in patients without PTD (P =0.023). With regard to serum creatinine, no significant differences were observed. Conclusion. PTD are frequent in type-1 diabetics receiving SPK and may have a role in relaparotomies, graft pancreatitis, and pancreas graft function.

Effects of hemodilution with a hemoglobin-based oxygen carrier (HBOC-201) on ischemia/reperfusion injury in a model of partial warm liver ischemia of the rat

BACKGROUND Ischemia/reperfusion injury is an unavoidable complication in liver surgery and transplantation. Hemodilution with colloids can reduce postischemic injury but limits oxygen transport. Hemoglobin-based oxygen carriers have been evaluated as blood substitute and provide a plasma-derived oxygen transport. It was the aim of our study to evaluate the combined benefits of hemodilution with a better oxygen supply to reperfused liver tissue by the use of HBOC-201 (Hemopure). MATERIAL AND METHODS A model of partial warm liver ischemia in the rat was used. One group served as untreated control, the other groups were hemodiluted either with Ringers lactate, Dextran-70, HBOC-201 or a mixture of Dextran and HBOC-201. After reperfusion, intravital microscopy studies were done and tissue pO(2) levels and transaminases measured. Statistical analysis was done by one- and two-way ANOVA, followed by pairwise comparison. RESULTS Hemodilution with Ringers lactate did not show any improvement compared to the control group. Dextran and HBOC group were superior to the Ringer and control animals in all parameters studied. Leucocyte adherence in postsinusoidal venules improved from 569.03+/-171.87 and 364.52+/-167.32 in control and Ringer group to 131.68+/-58.34 and 68.44+/-20.31/mm(2) endothelium in Dextran and HBOC group (p<0.001). Concerning tissue pO(2) levels, HBOC (23.4+/-5.0 mmHg) proved to be superior to Dextran (7.9+/-4.4 mmHg; p=0.007). CONCLUSION HBOC was equivalent to Dextran in reducing I/R injury in the liver, but improved oxygenation of postreperfusion liver tissue.

Simultaneous pancreas-kidney transplantation in patients with antiphospholipid syndrome

Background. Graft thrombosis is one of the main reasons of graft loss following simultaneous pancreas–kidney transplantation (SPK). Although antiphospholipid syndrome (APLS) is known as a high risk for graft thrombosis in kidney transplants alone, little is known about APLS in SPK. Methods. Between September 2000 and December 2001, 45 SPK were performed. The treatment and clinical course of 2 patients with APLS is presented. Results. In one patient, APLS was known before transplantation. After SPK, she was treated by systemic heparin followed by coumarin. Both grafts are doing well 5 months posttransplant. The second patient underwent SPK without knowledge of APLS. The patient developed a deep vein thrombosis 5 weeks posttransplant. Hypercoagulability screening revealed APLS. Treatment consisted of systemic anticoagulation. Grafts were not affected. Conclusion. SPK can successfully be performed in APLS patients if anticoagulation is performed consistently. To reduce the risk of graft thrombosis, a pretransplant screening for APLS would probably be of benefit.

Chirurgische Therapie des hepatozellulären Karzinoms

ZusammenfassungDie chirurgische Therapie des hepatozellulären Karzinoms (HCC) mit vollständiger Entfernung des Tumors oder die Lebertransplantation kann eine langfristige Heilung ermöglichen. Beide Verfahren sind primär oder im Rahmen neoadjuvanter Konzepte durchführbar. In bestimmten Fällen kann ein lokoregionäres Verfahren mit kurativer Zielsetzung angewandt werden. Die Zuordnung des Patienten zu einer primär chirurgisch kurativen, neoadjuvanten oder palliativen Vorgehensweise ist, neben der hepatischen und extrahepatischen Tumorausdehnung, von der vorbestehenden chronischen Leberschädigung abhängig. Die individuelle Grenze der Resektabilität ergibt sich aus der notwendigen Radikalität und dem für eine suffiziente postoperative Leberfunktion erforderlichen Parenchymrest. Aus diesem Grund ist das Ausmaß der zirrhotischen Leberschädigung für die Auswahl und die Sequenz der Therapiemaßnahmen entscheidend.AbstractSurgical treatment with complete resection of the hepatocellular carcinoma and liver transplantation can lead to a long term cure. If needed both surgical approaches can be incorporated into a neoadjuvant concept. In certain cases locoregional tumor treatment with curative intent can establish tumor control. Patients with established diagnosis are assigned to the corresponding surgical curative, neoadjuvant or palliative therapeutic approach according to the tumor stage and degree of parenchymal liver damage. The individual resection requirements to achieve tumor control and the acceptable limit of remnant liver volume to maintain liver function, define the individual feasibility of liver resection. For this reason sequence and choice of the therapeutic measures are determined by the extent of chronic functional impairment of the liver.

Telerobotic-assisted laparoscopic spleen-preserving partial resection of the pancreatic tail for insulinoma.

Laparoscopic pancreatic resection is rarely described. Telerobotic-assisted laparoscopy may offer some advantages for resection of the pancreatic tail. A 49-year-old woman was diagnosed with insulinoma located in the pancreatic tail. Telerobotic-assisted laparoscopic spleen-preserving resection of the pancreatic tail was performed. Operation time was 195 minutes. The postoperative course was uneventful. The previously described advantages of a telerobotic approach with extended range of motion and three-dimensional view make more complex operations like pancreatic resection possible and may offer extended indications for laparoscopic surgery.